FORM No. 1

INDUSTRIAL DESIGNS ACT 2001

APPLICATION FOR REGISTRATION OF A DESIGN

SINGLE APPLICATION IN RESPECT OF ONE DESIGN

1. Applicant(s) (Full name and address of each person or company applying.)

Name(s)
Address(es)
Nationality(ies)
Telephone(s)
Email(s)
Should additional space be required, please use an additional sheet, insert the appropriate section heading and attach to the completed form when filing.

2. Legal Representative (if any) (The following has been authorised to act on behalf of the Applicant(s) in all proceedings connected with this application for registration.)

Name
Address
Phone
Email

3. Address for Service (within the EEA, to which correspondence is to be sent.)

If different to the address given at 1 or 2 above
Address
Phone
Email
Please tick box if you wish the Office to correspond with you by Email in relation to this application

4. Representations

A representation of the design complying with the conditions set out in Regulation 11 of the Industrial Designs Regulations 2002, is enclosed. / Yes / No

5. Author(s)

(If there is more than one author (creator) of the design, insert here the name(s) and address(es) of the author(s).)

Name(s) of author(s) / Address(es)

6. Brief description of the design

7. Class(es) & Product(s)

Class(es)
(List here the class(es) including the subclass(es) of the Locarno system of International Classification in which registration of the design is requested.) / Product(s)
(List here the products to or in which the design is to be applied or incorporated.)

8. Priority

(If you have filed an application to register this Design outside the State within the last six months, please enter the relevant information here where a right to priority is claimed.)

State/Country/Territory/Area / Date / File Number (If available)

9. Deferment of Publication

(Is deferment of publication as provided for in Section 32(2) of the Principal Act requested? If yes, please indicate the period for which deferment is requested (the maximum period allowed is 30 months from the filing date or, if priority is claimed, from the date of priority.)

Yes / No / Period of deferment

10.  Fee(s) accompanying the application.

Application fee to register a design / (€ )
Deferment fee for a period up to 12 months / (€ )
Deferment fee for a period from 12 to 24 months / (€ )
Deferment fee for a period from 24 to 30 months / (€ )
Total: / (€ )

11. Declaration and Signature

(The application may be signed by a person authorised to do so by or on behalf of the Applicant(s) or by the legal representative named at 2.)

The Applicant(s) named herein claims to be the proprietor(s) of the design, a representation of which is attached, and requests the registration of the design on the basis of the foregoing information:
Signature
Name in BLOCK CAPITALS
If a company state the position in the company of the person signing
Date

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